Bankruptcy Questionnaire - Felden & Felden, P.A Questionnaire Return to: Felden and Felden, P.A., PO Box 1399, Jacksonville, NC 28541-1399 ... which either or both parties to the contract

Client Name: __________________________Page ____ of ____ Date: ____________________________

FELDEN AND FELDEN, P.A.

Bankruptcy Questionnaire

Return to: Felden and Felden, P.A., PO Box 1399, Jacksonville, NC 28541-1399

Bankruptcy is a time honored practice that affords honest debtors the opportunity for a fresh start. Everyone filing a

bankruptcy has experienced financial problems beyond his or her control. The court, trustees, and your attorney, understand

this and if you comply with their instructions, they will help you out of your financial crisis. In order to help you get the relief to

which you are entitled, you must make full disclosure of all your financial affairs. Do not try to second-guess the system – it

has been here longer than you.

Be sure to put your name at the bottom of each page and make sure to number them as well.

Assets. LIST ALL OF YOUR ASSETS. In all likelihood you will retain most, if not all, of your assets after the bankruptcy.

Do not jeopardize your discharge by omitting anything. You can list assets by groups of similar property, i.e. “furniture”,

“clothing”, “personal effects”, etc. Your attorney will tell you how large or small your groupings can be.

Keep in mind, when determining the “fair market value” of collateral, use the amount you could sell the item for, NOT

what you paid for it

Debts. LIST ALL OF YOUR DEBTS. You may plan to repay some creditors, including relatives and friends, but you must,

nevertheless, list them as creditors. Your attorney can discuss with you the procedure for “reaffirming” a debt to a creditor or

how to go about repaying your relatives or friends. If you have debts that are disputed, list them. If you have potential debts

for which no one has yet made a direct claim against you, list them. If in doubt as to whether a creditor should be listed, list

them. LIST ALL OF YOUR DEBTS. Failure to list a creditor can result in you not being discharged of your obligation to that

creditor.

Executory Contracts. These are contracts such as leases, real estate contracts, health clubs, time-shares, etc., for

which either or both parties to the contract have not yet fully performed their obligations under the contract. In all likelihood

you should also list these parties as creditors too.

Co-debtors. Your co-debtors are obligated to pay the debts you do not. For most people, a co-debtor is just

someone who co-signed a loan. However, partners, spouses and others who are not part of your petition may be liable on

many of your debts without actually co-signing anything. If this is your situation you will need to attach additional sheets listing

all debts for which someone else may be jointly liable, or those debts that you co-signed for another party.

Income. You must disclose your income over the last 6 months. If you are employed, you will need to provide a pay

stubs for at least the last 60 days. If you are self-employed or you are a corporation or partnership, attach a financial statement

showing your monthly income.

Expenditures. The accuracy of your estimated living expenses is essential. The trustees assigned to your case will

scrutinize budgets carefully. Budgets will be compared to standards published by the IRS for your county of residence. To the

extent your needs differ, your attorney can advise you about your alternatives.

If you are a partnership or a corporation, submit a financial statement indicating your monthly business expenses.

Individuals who are in business for themselves should include a detailed statement of their business expenses in addition to the

personal expenses called for in this questionnaire.

If at any time you have questions while completing this form, please do not hesitate to contact us at 888-808-9291.



General Information

Please fill out ALL of the information requested in these forms. If a question or section does NOT apply to you, please write “N/A” in the space

provided. (N/A means “not applicable”.) The more information you provide in these forms, the faster your bankruptcy petition can be prepared.

Thank you in advance for taking the time to be thorough and complete, resulting in a faster turnaround of your case.

Name: First _______________________ Middle _______________________ Last___________________________

Social Security Number: __________________________________________________________________________

Street Address: _________________________________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________

County of Residence: _______________________________ Length of time at this address: ___________________

Home Phone: _____________________________________ Cell Phone: ___________________________________

Email address: _________________________________________________________________________________

Mailing Address (if different than street address): _____________________________________________________

_____________________________________________________________________________________________

Spouse Name: First ____________________ Middle ____________________ Last___________________________

Spouse Social Security Number: ___________________________________________________________________

Spouse Street Address: __________________________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________

County of Residence: _______________________________ Length of time at this address: ___________________

Home Phone: _____________________________________ Cell Phone: ___________________________________

Spouse Email address: ___________________________________________________________________________

Spouse Mailing Address (if different than street address): ______________________________________________

_____________________________________________________________________________________________

Have you resided in the same county for at least 180 days (6 months)? ⃝ Yes ⃝ No

If not, where have you resided? ___________________________________________________________________

Are you filing this bankruptcy petition with your spouse? ⃝ Yes ⃝ No

If not, please provide the reason: ⃝ Unmarried ⃝ Spouse filing separately ⃝ Separated ⃝ Other reason

Have you filed bankruptcy within the last eight (8) years? ⃝ Yes ⃝ No

If yes, please provide the date and location of your filing: _______________________________________________



Dependents:

1. Name: ___________________________ Age:_________ Relationship to you: __________________

Resides with you: ⃝ Yes ⃝ No







Other Information:

Have either you or your spouse been known by any other name during the past 8 years? (Example: maiden name,

last name from previous marriage, legal name change, etc.) ⃝ Yes ⃝ No

Name Used: _______________________________________________Dates Used: ____________ to ___________

Name Used: _______________________________________________Dates Used: ____________ to ___________

Has your income significantly increased or decreased during the past six (6) months? If so, please provide details

below: _______________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________



Your Real Estate

Note: If you own a Mobile Home, please fill out the next page. Print out additional pages for every separate piece of real estate that you own.

Check the type of real estate that you own: ⃝ House ⃝ Condominium ⃝ Land ⃝ Timeshare/Other: _________

Name(s) on Deed: ______________________________________________________________________________

Description of Property (example: 1,250 square foot single family home with 2 bedrooms, 2 baths, attached 2-car

garage, situated on 2 acres of land with outbuildings):

_____________________________________________________________________________________________

Street Address of Property: _______________________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________

Name of 1st

Mortgage Company: __________________________________________________________________

Address of 1st

Mortgage Company: _________________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________

Account Number: _____________________________________ Monthly payment amount: ___________________

What is the payoff on this mortgage? ______________________ Are you behind on payments? ⃝ Yes ⃝ No

By what amount are you behind? _________ What is the current market value of this property? _______________

What is your intention with this property? ⃝ Keeping ⃝ Surrendering

Is there a 2nd

mortgage on this property? ⃝ Yes ⃝ No

Name of 2nd

Mortgage Company (if applicable): _______________________________________________________

Address of 2nd

Mortgage Company: ________________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________



By what amount are you behind? _________

Name of Collection Agency or Attorney (if applicable): _________________________________________________

Address: ______________________________________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________

Is this property currently in foreclosure? ⃝ Yes ⃝ No

If in collections or foreclosure, please provide a copy of all court documents you received.



Your Mobile Home

Print out additional pages for every mobile home that you own.

Name(s) on Title: ______________________________________________________________________________

Description of Mobile Home (example: 28x40 doublewide, 2 bedroom, 1 bath, on wheels with skirting and steps

and 1 outbuilding shed, situated in mobile home park):

_____________________________________________________________________________________________

Street Address of Mobile Home: ___________________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________

Does your mobile home sit in a mobile home park? ⃝ Yes ⃝ No What is the monthly lot rent? ___________

Does your mobile home sit on a piece of ground that you own? ⃝ Yes ⃝ No USE YOUR REAL ESTATE PAGE FOR THIS

Name of 1st

Mortgage Company: __________________________________________________________________

Address of 1st

Mortgage Company: _________________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________



By what amount are you behind? _________ What is the current market value of this mobile home? ___________


Is there a 2nd

mortgage on this property? ⃝ Yes ⃝ No

Name of 2nd

Mortgage Company (if applicable): _______________________________________________________

Address of 2nd

Mortgage Company: ________________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________



By what amount are you behind? _________

Name of Collection Agency or Attorney (if applicable): _________________________________________________

Address: ______________________________________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________

Is this property currently in foreclosure? ⃝ Yes ⃝ No

If in collections or foreclosure, please provide a copy of all court documents you received.



Your Household Inventory

Please check the items below that you own. Please provide the current GARAGE SALE VALE of each item - NOT the replacement cost.

⃝ Stove/Cooking Unit $ _________ ⃝ Guns/Firearms $ _________

⃝ Refrigerator $ _________ ⃝ Lawnmower $ _________

⃝ Washer/Dryer $ _________ ⃝ Boat $ _________

⃝ Microwave $ _________ ⃝ Trailer $ _________

⃝ Cooking Utensils $ _________ ⃝ Camper $ _________

⃝ Silverware $ _________ ⃝ Rental Deposit $ _________

⃝ Pots/Pans/Cookware $ _________ Landlord: ________________________

⃝ Living Room Furniture $ _________ ________________________________

⃝ Dining Furniture $ _________ ⃝ Security Deposit $ _________

⃝ Television(s) #______ $ _________ Company: ________________________

⃝ DVD(s) $ _________ _________________________________

⃝ DVD Player(s) $ _________ ⃝ Government Bonds $ _________

⃝ CD(s) $ _________ ⃝ Certificates of Deposit $ _________

⃝ Other Stereo Items $ _________ ⃝ Copyright/Patent $ _________

⃝ Bedroom Furniture $ _________ ⃝ Aircraft $ _________

⃝ Lamps/Accessories $ _________ ⃝ Education IRA $ _________

⃝ Computer $ _________ ⃝ Customer List $ _________

⃝ Printer $ _________ ⃝ __________________ $ _________

⃝ Desk/Office Furniture $ _________ ⃝ __________________ $ _________

⃝ Wedding Ring(s) $ _________ ⃝ __________________ $ _________

⃝ Other Jewelry Items $ _________ ⃝ __________________ $ _________

⃝ Furs $ _________ ⃝ __________________ $ _________

⃝ All Clothing $ _________ ⃝ __________________ $ _________

⃝ Photography Items $ _________ ⃝ __________________ $ _________

⃝ Collectibles $ _________ ⃝ __________________ $ _________

⃝ Paintings/Art $ _________ ⃝ __________________ $ _________

⃝ Tools $ _________ ⃝ __________________ $ _________



Your Motor Vehicles

Motor vehicles include cars, trucks, SUVs, motorcycles, RVs, boats, trailers, campers, etc. that are titled in your and/or your spouse’s name.

Print out additional pages for additional that you own.

Check the type of vehicle: ⃝ Car ⃝ Truck ⃝ Motorcycle ⃝ Other: ____________________________________

Year: _________ Make: ____________________ Model: ______________ Current Market Value: ______________

Name(s) on Title: _______________________________________________________________________________

Is this vehicle leased? ⃝ Yes ⃝ No If yes, what is the “buy out” of the lease? __________________________

Name of company you make payments to for this vehicle: ______________________________________________

Address of Company: ____________________________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________


What is the payoff on this vehicle? ______________________ Are you behind on payments? ⃝ Yes ⃝ No

By what amount are you behind? _______________ Date vehicle was purchased/financed: ___________________


Check the type of vehicle: ⃝ Car ⃝ Truck ⃝ Motorcycle ⃝ Other: ____________________________________

Year: _________ Make: ____________________ Model: ______________ Current Market Value: ______________

Name(s) on Title: _______________________________________________________________________________

Is this vehicle leased? ⃝ Yes ⃝ No If yes, what is the “buy out” of the lease? __________________________

Name of company you make payments to for this vehicle: ______________________________________________

Address of Company: ____________________________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________


What is the payoff on this vehicle? ______________________ Are you behind on payments? ⃝ Yes ⃝ No

By what amount are you behind? _______________ Date vehicle was purchased/financed: ___________________




Debt Sheet 1 of 5

Print out additional pages if you need more space for listing creditors, or feel free to continue on the back of this sheet.

DO NOT JUST LIST DEBTS YOU WANT TO INCLUDE – LIST EVERY DEBT YOU OWE, EVEN LOANS FROM RELATIVES.

Name of creditor: _______________________________________________________________________________

Address of creditor: ____________________________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________

Account Number: _____________________________________ Total amount owed: ________________________

Type of debt: ⃝ Credit Card ⃝ Medical Bill ⃝ Personal Loan ⃝ Student Loan ⃝ Other: ____________

Who is responsible for this debt? ⃝ Husband ⃝ Wife ⃝ Both ⃝ Other/Co-debtor:__________________

Has this debt been turned over to a collection agency? ⃝ Yes ⃝ No

Name of collection agency or law firm: ______________________________________________________________

Address of collection agency:______________________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________

Name of creditor: _______________________________________________________________________________


City: _____________________________________ State: ___________________ Zip: ________________________







City: _____________________________________ State: ___________________ Zip: ________________________



Debt Sheet 2 of 5

Name of creditor: _______________________________________________________________________________


City: _____________________________________ State: ___________________ Zip: ________________________







City: _____________________________________ State: ___________________ Zip: ________________________

Name of creditor: _______________________________________________________________________________


City: _____________________________________ State: ___________________ Zip: ________________________







City: _____________________________________ State: ___________________ Zip: ________________________



Debt Sheet 3 of 5

Name of creditor: _______________________________________________________________________________


City: _____________________________________ State: ___________________ Zip: ________________________







City: _____________________________________ State: ___________________ Zip: ________________________

Name of creditor: _______________________________________________________________________________


City: _____________________________________ State: ___________________ Zip: ________________________







City: _____________________________________ State: ___________________ Zip: ________________________



Debt Sheet 4 of 5

Name of creditor: _______________________________________________________________________________


City: _____________________________________ State: ___________________ Zip: ________________________







City: _____________________________________ State: ___________________ Zip: ________________________

Name of creditor: _______________________________________________________________________________


City: _____________________________________ State: ___________________ Zip: ________________________







City: _____________________________________ State: ___________________ Zip: ________________________



Debt Sheet 5 of 5

Name of creditor: _______________________________________________________________________________


City: _____________________________________ State: ___________________ Zip: ________________________







City: _____________________________________ State: ___________________ Zip: ________________________

Name of creditor: _______________________________________________________________________________


City: _____________________________________ State: ___________________ Zip: ________________________







City: _____________________________________ State: ___________________ Zip: ________________________



Your Income Information

DEBTOR (HUSBAND)

Year to date total income: ___________ Total income last year: ___________ Total income two years ago: ___________

⃝ Monthly – You get paid once each month – 12 checks per year

⃝ Semi-Monthly – You get paid twice each month (i.e. 1st

and 15th

) – 24 checks per year

⃝ Bi-Weekly – You get paid every other week (i.e. every other Friday) – 26 checks per year

⃝ Weekly – You get paid once each week – 52 checks per year

Income from your paystub (PER PAY PERIOD) Other Monthly Income (PER MONTH)

Gross Income $ _________ From your business $ _________

Estimated Overtime $ _________ From real property $ _________

Interest and Dividends $ _________

Payroll Deductions Pension/Retirement $ _________

Federal Income Tax $ _________ Alimony, child support $ _________

State Income Tax $ _________ Social Security $ _________

FICA/Medicare $ _________ Gov. Assistance $ _________

Insurance $ _________ Other: ____________ $ _________

Union Dues $ _________ Other: ____________ $ _________

Other: ____________ $ _________ Other: ____________ $ _________

Other: ____________ $ _________ Other: ____________ $ _________

Explain any anticipated increase or decrease in income of more than 10% in the next year. ____________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________



Your Spouse’s Income Information

CO-DEBTOR (WIFE)

Year to date total income: ___________ Total income last year: ___________ Total income two years ago: ___________

⃝ Monthly – You get paid once each month – 12 checks per year

⃝ Semi-Monthly – You get paid twice each month (i.e. 1st

and 15th

) – 24 checks per year

⃝ Bi-Weekly – You get paid every other week (i.e. every other Friday) – 26 checks per year

⃝ Weekly – You get paid once each week – 52 checks per year

Income from your paystub (PER PAY PERIOD) Other Monthly Income (PER MONTH)

Gross Income $ _________ From your business $ _________

Estimated Overtime $ _________ From real property $ _________

Interest and Dividends $ _________

Payroll Deductions Pension/Retirement $ _________

Federal Income Tax $ _________ Alimony, child support $ _________

State Income Tax $ _________ Social Security $ _________

FICA/Medicare $ _________ Gov. Assistance $ _________

Insurance $ _________ Other: ____________ $ _________

Union Dues $ _________ Other: ____________ $ _________

Other: ____________ $ _________ Other: ____________ $ _________

Other: ____________ $ _________ Other: ____________ $ _________

Explain any anticipated increase or decrease in income of more than 10% in the next year. ____________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________



Your Monthly Budget

This form is used to determine how much you spend each month on living expenses. Be sure to write in the MONTHLY (not yearly) amounts for

each expense. For utilities, your bill may be higher in the winter than in the summer, so please use averages that will cover a 12 month period.

Housing Expenses Taxes

Rent $ _________ Other than deductions $ _________

First Mortgage $ _________ Other Expenses

Second Mortgage $ _________ Alimony or Child Support $ _________

Third Mortgage $ _________ Charitable Giving $ _________

Lot Rent $ _________ Payments for other $ _________

Real Estate Taxes $ _________ dependents. Explain: _______________

(if not in mortgage) ________________________________

Insurance $ _________ Child Care Expenses $ _________

(if not in mortgage) School Expenses $ _________

Utilities School Lunch Expenses $ _________

Electricity/Gas $ _________ Personal Care $ _________

Water $ _________ ⃝ __________________ $ _________

Telephone $ _________ ⃝ __________________ $ _________

Cable/Internet $ _________ ⃝ __________________ $ _________

Trash Pick-Up $ _________ ⃝ __________________ $ _________

Laundry/Dry Cleaning $ _________ ⃝ __________________ $ _________

Medical Expenses $ _________ ⃝ __________________ $ _________

Transportation ⃝ __________________ $ _________

Gasoline/Maintenance $ _________ ⃝ __________________ $ _________

Vehicle Payment $ _________ ⃝ __________________ $ _________

Vehicle Payment $ _________ ⃝ __________________ $ _________

Insurance ⃝ __________________ $ _________

Renters Insurance $ _________ ⃝ __________________ $ _________

Life Insurance $ _________ ⃝ __________________ $ _________

Health Insurance $ _________ ⃝ __________________ $ _________

Automobile Insurance $ _________ ⃝ __________________ $ _________



Statement of Financial Affairs (1 of 13)

The following pages contain important questions, many of which will be asked of you again by the Trustee when you attend your 341 Meeting.

Please take your time and go through every question thoroughly, providing as much detail as possible to the questions you answer “yes”.

List the names of all spouses (past and present) that you have been married to, as well as the dates you were

married:

Full Name (First, Middle, Last): ____________________________________________________________________

Dates Married: From _________________________ to _________________________







Have you ever provided a notice to any governmental unit of a Release of Hazardous Materials?

If so, list the name and address of every site for which you have provided notice to a governmental unity of a

release of Hazardous Material. Indicate the governmental unit to which the notice was sent and the date of notice.

Name/Address of Site ______________________ Governmental Unit Notice Sent To: ______________________

Do you share the ownership of any real property with another person, such as a co-tenancy or joint tenancy?

(This does not apply to your spouse) ⃝ Yes ⃝ No

Name of person: _______________________________________________________________________________

Do you have a future interest in any real estate, such as putting money down on a property you have not

purchased yet? ⃝ Yes ⃝ No

If so, please provide details: ______________________________________________________________________

Do you own or are you buying a time-share in a vacation property or resort? ⃝ Yes ⃝ No

If so, please provide details: ______________________________________________________________________




Do you have a car, truck, motorcycle, etc. in your possession titled in someone else’s name? ⃝ Yes ⃝ No

If so, please provide details: Year ________________Make ________________Model _______________________

Whose name is the vehicle titled to? _______________________________________________________________

Their address: _________________________________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________

What is this person’s relationship to you? ___________________________________________________________

Why are you holding this property in your possession? _________________________________________________

Are you buying any of your furniture or appliances with installment payments? ⃝ Yes ⃝ No

Description of Item(s)

1. _____________________________________________________________ Yard Sale Value $___________

2. _____________________________________________________________ Yard Sale Value $___________

3. _____________________________________________________________ Yard Sale Value $___________

Name of Company you make installment payments to: _________________________________________________

MAKE SURE THESE DEBTS ARE LISTED ON THE DEBT SHEETS

Are you renting-to-own any of your furniture or appliances? ⃝ Yes ⃝ No


1. _____________________________________________________________ Yard Sale Value $___________

2. _____________________________________________________________ Yard Sale Value $___________

3. _____________________________________________________________ Yard Sale Value $___________



Have you listed any of your personal items as collateral to obtain a loan? ⃝ Yes ⃝ No


1. _____________________________________________________________ Yard Sale Value $___________

2. _____________________________________________________________ Yard Sale Value $___________

3. _____________________________________________________________ Yard Sale Value $___________






Do you own or are you buying any tools or equipment that you use for work? ⃝ Yes ⃝ No


1. _____________________________________________________________ Yard Sale Value $___________

2. _____________________________________________________________ Yard Sale Value $___________

3. _____________________________________________________________ Yard Sale Value $___________



Do you currently have any inventory (stock in trade) that can be sold for $200+ in profit? ⃝ Yes ⃝ No


1. _____________________________________________________________ Yard Sale Value $___________

2. _____________________________________________________________ Yard Sale Value $___________

3. _____________________________________________________________ Yard Sale Value $___________

Are you buying any jewelry with installment payments? ⃝ Yes ⃝ No


1. _____________________________________________________________ Yard Sale Value $___________

2. _____________________________________________________________ Yard Sale Value $___________

3. _____________________________________________________________ Yard Sale Value $___________



Do you have any animals, livestock or pets you could sell for $200+? ⃝ Yes ⃝ No

Description of Animals(s)

1. _____________________________________________________________ Value $___________________

2. _____________________________________________________________ Value $___________________

3. _____________________________________________________________ Value $___________________




Do you have any checking or savings account(s) at this time? ⃝ Yes ⃝ No

Name of Bank: _________________________________________________________________________________

Branch Address: ________________________________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________

Type of Account: ⃝ Checking ⃝ Savings ⃝ Both ⃝ Other: _____________________________________

Name(s) on account: ____________________________________________________________________________

Account number for Checking: ___________________________________________ Present Balance: ___________

Account number for Savings: ___________________________________________ Present Balance: ____________

Do you have any secondary checking or savings account(s) at this time? ⃝ Yes ⃝ No

Name of Bank: _________________________________________________________________________________

Branch Address: ________________________________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________


Name(s) on account: ____________________________________________________________________________

Account number for Checking: ___________________________________________ Present Balance: ___________

Account number for Savings: ___________________________________________ Present Balance: ____________

Have you closed any bank accounts within the past two (2) years? ⃝ Yes ⃝ No

Name of Bank: _________________________________________________________________________________

Branch Address: ________________________________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________


Name(s) on account: ____________________________________________________________________________

Account number: _______________________________ Date Closed: ___________Closing Balance: ____________

Did you owe a balance when you closed this account? ⃝ Yes ⃝ No Balance owed: ____________________

MAKE SURE THIS DEBT IS LISTED ON THE DEBT SHEETS




Do you have or have you rented a safe deposit box during the past two (2) years? ⃝ Yes ⃝ No

Name of Bank: _________________________________________________________________________________

Branch Address: ________________________________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________

What are the contents of the safe deposit box? _______________________________________________________

_____________________________________________________________________________________________

What monthly amount do you pay for rental of this deposit box? ________________________________________

If you no longer have the safe deposit box, what date did you surrender it? ________________________________

If you transferred the safe deposit box, who did you transfer it to? _______________________________________

Do you have a Christmas Club Account or any other special purpose accounts? ⃝ Yes ⃝ No

Name of Bank: _________________________________________________________________________________

Branch Address: ________________________________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________

Type of Account: _______________________________ Account Number: _________________________________

Name(s) on the Account: ________________________________________ Present Balance: __________________

Do you have any security deposits being held by a utility company? ⃝ Yes ⃝ No If yes, what amount? _____

Name of Utility Company: ________________________________________________________________________

Address of Utility Company: ______________________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________

Account Number: _________________________________ Present Balance: _______________________________

Remember to include any past-due utility bills that you owe from previous addresses on your debt sheets.




Do you have any life insurance? ⃝ Yes ⃝ No

Name of Insurance Company: _____________________________________________________________________

If a “whole life” policy, what is the current cash value? _________________________________________________

If your life insurance is only payable upon death, what is the face value of the policy? ________________________

Who is the beneficiary? _______________________________ Relationship: _______________________________

If you have other life insurance policies, please list the information above for each one on the back of this page.

Do you or your spouse participate in a retirement, 401K or pension plan? ⃝ Yes ⃝ No

Type of pension plan (i.e. 401K, PERS, etc.): __________________________________________________________

When did you first enroll in this plan? __________________________________ Current cash value: ____________

Have you set up your own separate retirement account, not provided by your employer? ⃝ Yes ⃝ No

Name of Financial Institution: ________________________________________ Current cash value: ____________

Who is the beneficiary? _____________________________________ Relationship: _________________________

Will you receive retirement benefits from a previous employer within the next six (6) months? ⃝ Yes ⃝ No

Date you expect to start receiving retirement benefits: _________________________________________________

Do you have any stocks, bonds (including savings bonds) or mutual funds? ⃝ Yes ⃝ No

Type of bond, stock, mutual fund: __________________________________________________________________

Does this bond, stock or mutual fund have a cash value? ⃝ Yes ⃝ No Cash Value:______________________

Do you have a cell phone? ⃝ Yes ⃝ No Do you wish to continue the monthly contract? ⃝ Yes ⃝ No

Name of Cell Phone Company: ____________________________________________________________________

Address of Cell Phone Company: ___________________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________

Account Number: _______________ Date Contract began: __________ What is the average monthly bill? _______

Is this a month-to-month contract? ⃝ Yes ⃝ No If not, what is the length of the contract? ______________

If you have other cell phone contracts, please list the information above for each one on the back of this page.




Do you live with a roommate/relative who pays part of your expenses? ⃝ Yes ⃝ No

Name of Roommate or relative: ___________________________________Relationship: _____________________

What expenses do they pay? ______________________________________________________________________

What is the total amount they contribute? _______ How long have they been paying this amount? _____ to _____

Do relatives or other parties help to pay part or all of your monthly expenses? ⃝ Yes ⃝ No

Name of relative providing additional support: _____________________________Relationship: _______________

What is the total amount they contribute? _______ How long have they been paying this amount? _____ to _____

Are you currently attending college? ⃝ Yes ⃝ No

Name of College: _______________________________________________________________________________

Anticipated graduation date: ______________ Major of study: __________________________________________

Do you have a student loan? ⃝ Yes ⃝ No

Name of Student Loan Company: __________________________________________________________________

Address of Student Loan Company: ________________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________

Total amount owed: _______________ Date payments began: __________ Average monthly bill: ______________

Do you currently owe any fines (including parking tickets, moving violations, etc.)? ⃝ Yes ⃝ No

Name of Court you owe fines to: __________________________________________________________________

Address of Court you owe fines to: _________________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________

Total amount owed: _______________ Date of occurrence: __________ Case number: ______________________

What was this fine for? __________________________________________________________________________




If you pay child support, are you currently behind on payments? ⃝ Yes ⃝ No

Name of person/agency you pay child support to: _____________________________________________________

Address of person/agency you pay child support to: ___________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________

Total amount owed in back support: _______________ What date were you supposed to start payments: _______

What are the payment arrangements? ______________________________________________________________

Even if you never expect to collect, does an ex-spouse owe you alimony or child support? ⃝ Yes ⃝ No

Name of ex-spouse: _____________________________________________________________________________

Address of ex-spouse: ___________________________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________

Total amount owed in back support: _______________ What date were payments supposed to start: ___________

Has this ex-spouse been court ordered to pay you? ⃝ Yes ⃝ No Year of court order: ___________________

Over the last year, have you, your children or your spouse been involved in an accident? ⃝ Yes ⃝ No

Who was involved in the accident: ___________________ Who was at fault? ______________________________

Date accident occurred: _________ Was any insurance money received? ⃝ Yes ⃝ No How much? ________

During the next six (6) months, do you expect to inherit anything? ⃝ Yes ⃝ No

How much do you expect to inherit? ______________________________ Date expected: ____________________

Reason for inheritance: __________________________________________________________________________

During the next six (6) months, do you expect to receive anyone’s life insurance proceeds? ⃝ Yes ⃝ No


Reason for receiving money: ______________________________________________________________________

Do you expect to receive any money from any insurance claim, during the next six (6) months? ⃝ Yes ⃝ No


Reason for receiving money: ______________________________________________________________________




Are you the beneficiary of a trust fund? ⃝ Yes ⃝ No

What is the amount of the trust fund? __________ Name of trust fund owner: _____________________________

Relationship to you: ________________ When will you have access to this trust fund? _______________________

Are you owed any back wages, commissions or vacation pay from an employer? ⃝ Yes ⃝ No

Employer Name: _______________________________________________________________________________

Amount expected to receive: _____________________________ Date expected to receive: ___________________

Please provide details about this amount that is owed to you. Feel free to the back of this page if necessary.

Is any of your property in the hands of a repairman, storage or pawn? ⃝ Yes ⃝ No

Name of place holding your property: ______________________________________________________________

Address of place holding your property: _____________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________


1. _____________________________________________________________ Yard Sale Value $___________

2. _____________________________________________________________ Yard Sale Value $___________

3. _____________________________________________________________ Yard Sale Value $___________

What is the total amount you need to pay in order to get these items released? ____________________________

In the near future, do you expect to settle, win or begin a case for personal injury? ⃝ Yes ⃝ No

How much do you expect to receive? __________ Date you expect to receive this money: ____________________

Please provide details about this personal injury claim: _________________________________________________

_____________________________________________________________________________________________

Name of attorney or law firm handing this claim: _____________________________________________________

In the near future, do you expect to enter into any property settlement with a former spouse? ⃝ Yes ⃝ No

List all items you expect to receive or turn over in the property settlement (including cash): _________________

____________________________________ What is the total yard sale value of these items? _________________

When do you expect to receive or turn over this property? _____________________________________________




Does anyone owe you any money for a judgment you have against them? ⃝ Yes ⃝ No

Name of party you filed a lawsuit against: ___________________________________________________________

Address of party you filed a lawsuit against: __________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________

Date you filed this lawsuit: _____________ Amount awarded to you in judgment: ___________________________

Even if you never expect to collect, does anyone owe you any money? ⃝ Yes ⃝ No

Name of party who owes you money: ______________________________________________________________

Address of party who owes you money: _____________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________

Explain why they owe you money: __________________________________ Amount they owe you: ____________

Have you made any payments to any creditors other than ordinary payments? ⃝ Yes ⃝ No

Name of creditor you paid: _______________________________________________________________________

Date paid: __________________ Amount paid: ________________ Current Balance Due: ____________________

Name of creditor you paid: _______________________________________________________________________

Date paid: __________________ Amount paid: ________________ Current Balance Due: ____________________

Are there any lawsuits pending against you? ⃝ Yes ⃝ No

Name of party suing you (plaintiff): ________________________________________________________________

Case Number: __________________ Date filed: ________________ Type of Lawsuit: ________________________

Attorney for the Plaintiff: ________________________________________________________________________

Address of Attorney: ____________________________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________

Please provide a copy of all court documents. Feel free to the back of this page to list additional lawsuits.

Have your wages or property been garnished or attached? ⃝ Yes ⃝ No

Who garnished your wages or attached your property? ________________________________________________

What item was repossessed? ________________ How much was garnished? _________ How often? ___________




Have you returned any property to creditors, or was any property repossessed or foreclosed? ⃝ Yes ⃝ No

What property did you turn over to a receiver? _______________________________________________________

When and where did this take place? _______________________________________________________________

Is any of your property in receivership or other legal custody? ⃝ Yes ⃝ No

When did you file your receivership? _______________________________________________________________

In what court was this done? _____________________________________________________________________

Have you made any gifts to friends or relatives? ⃝ Yes ⃝ No

What gifts or transfers have you made? _____________________________________________________________

Who did you give the gift to? ___________________________________ What is the approximate value? ________

Have you transferred any money or property to family members or friends? ⃝ Yes ⃝ No

Type of property transferred: _____________________________________________________________________

What date was it transferred? ____________________________ What is the approximate value? ______________

Have you had any unusual losses, such as fire, theft, gambling or otherwise? ⃝ Yes ⃝ No

Type of loss: ⃝ Fire ⃝ Theft ⃝ Gambling ⃝ Other:____________________________________________

What items or amount of money was lost? __________________________________________________________

Date of loss: _____________________________ Amount insurance paid:__________________________________

Have you had any losses covered by insurance? ⃝ Yes ⃝ No

Describe loss: __________________________________________________________________________________

Date of loss: _____________________________ Amount insurance paid:__________________________________




Have you paid money to an attorney or debt counseling agency? ⃝ Yes ⃝ No

Name of attorney or service: ______________________________________________________________________

Address of attorney or service: ____________________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________

Consultation Date: __________________________________ Total paid for service: _________________________

Have you filed any bankruptcy within the last eight (8) years? ⃝ Yes ⃝ No

Chapter filed: ⃝ Chapter 7 ⃝ Chapter 13 ⃝ Chapter 11

Date filing took place: _________________ Case Number: ______________________________________________

City and State where filed: ______________________________ Was the case discharged? ⃝ Yes ⃝ No

Name of person(s) who filed: _____________________________________________________________________

Is anyone holding any property that belongs to you? ⃝ Yes ⃝ No

Name of person holding your property: _____________________________________________________________

Address of person holding your property: ___________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________

Description of Item(s) :___________________________________________________________________________

Besides your current address, have you lived at any other address within the past six (6) years? ⃝ Yes ⃝ No

Previous address: _______________________________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________

Time period you lived at this address: From (date/year) __________________ to (date/year) __________________

Names of parties who lived at this address:__________________________________________________________

Previous address: _______________________________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________

Time period you lived at this address: From (date/year) __________________ to (date/year) __________________

Names of parties who lived at this address:__________________________________________________________

Feel free to the back of this page to list additional addresses, if necessary.




Have you been self-employed or had any interest in a business within the past either (8) years? ⃝ Yes ⃝ No

Name of business: ______________________________________________________________________________

Address of business: ____________________________________________________________________________

City: _____________________________________ State: ___________________ Zip: ________________________

Type of business: ______________________ Date business began: __________ Date business ended: __________

Name(s) of your partners, co-investors, or associates: __________________________________________________

What were your net profits for this year? ____________ Last year? ____________ Two years ago? _____________

How much income tax do you pay from the income you make within your business? _________________________

During the past two (2) years, have either you or your spouse had any other income source? ⃝ Yes ⃝ No

Additional Income for this year? ______________ Last year? _______________ Two years ago? _______________

How much income tax do you pay from the income you make within your business? _________________________

Did you receive a tax refund this year? ⃝ Yes ⃝ No Amount of refund: _______________

⃝ I did not file taxes. OR ⃝ I had to pay taxes and did not receive a refund

By signing below, I state that all the information provided in these client intake forms are true, accurate and

complete to the best of my/our knowledge.

__________________________________________ __________________________________________

Signature of Debtor Signature of Co-Debtor

Date: _____________________________________ Date: _____________________________________

Documents

Bankruptcy Questionnaire - Felden & Felden, P.A Questionnaire Return to: Felden and Felden, P.A., PO Box 1399, Jacksonville, NC 28541-1399 ... which either or both parties to the contract